Overstay Predictor Project

Overstay Predictor Project for Medicine - collection team meeting discussion

• Primary Investigator: Dr. Dan Roberts

Pilot Information

Official pilot start data for the Grace has been delayed, meeting to discuss new plans is scheduled for May 3. Please continue the informal testing that has been going on for the last few days. Thanks! Ttenbergen 14:19, 2012 April 30 (CDT)

• thank you Stephanie and Sheila for super feedback.Trish Ostryzniuk 15:32, 2012 April 30 (CDT)

Instructions

For every medicine patient at the Grace hospital, as soon as possible, but definitely within 48 business hrs of admission:

• find the new "Overstay" form on the chart
• for the first 6 check boxes on the form, create a record for each in tmp entries and check the checkbox if the answer is Yes. (one to one from the form, no interpretation necessary)
• (I will add a picture of the form here once we have a final version)
• Also, enter at least all the following as part of minimal dataset
  • DOB
  • Admit Date
  • ADLs
  • whether there was any CVA or Dementia as a comorbid
  • whether there was a stroke as an admit diagnosis

• Click the new “Overstay” button on the patient viewer form next to the notes field and it will turn a colour:
  • GREEN - low/no risk for discharge issues
  • YELLOW - some risk for discharge issues
  • RED - significant risk for discharge issues.
  • GRAY - if some needed data is missing
• colors based on an underlying algorithm too complicated to get into here, but based on tmp entries, age, comorbids, admit dxs and ADLs

• • If the chart already has a sticker the same colour then you are done
  • if the colour in the program is different from the one on the chart put a sticker of the program colour over the sticker on the chart. Stickers will be supplied.

If you can't find data

• I have emailed Linda to please fill in who the collector should talk to if there are problems with the Overstay form or the other data required for the project in a timely manner.Ttenbergen 14:45, 2012 April 23 (CDT)

Questions

location of form and sticker

Where on the chart will this new form be and will it be a colored form?Trish Ostryzniuk 10:43, 2012 April 24 (CDT)

• not known yet, will add details when we get them. Ttenbergen 12:56, 2012 April 27 (CDT)

no need to document sticker colour changes

1. Will it be necessary to document a difference in sticker colours if we need to change the colour once the algorithm has run?
   • no need. The original colour is based on the items you enter into tmp, so we can go back from that if needed. Ttenbergen 12:47, 2012 April 27 (CDT)

test scenarios for colours

1. How can I test the yellow colour?-I can only get the overstay button to be red or green using multiple different combinations of the check boxes
   • yellow would be based on a combination of comorbids and ADLs and age. Make a patient a little less sick and they will become yellow. Sorry, can't give you exact instructions, the algorithm is pretty messy. Ttenbergen 12:47, 2012 April 27 (CDT)

admission times and conditions at admission

The time we use as the time of admission will be different than the time of admission to the unit, and often significant time has passed between the 2 times so the information collected is different e.g. pt is confused at our admission time but by the time the patient goes to the unit, the patient is now A & O etc or vice versa. Will this affect the algorithm?

• Use the data as you would have entered before as that is what the algorithm was based on. I hope that helps, since I know some collectors used to collect this much later. Pls let me know if you need more info. Ttenbergen 12:47, 2012 April 27 (CDT)

1. what if our assessment differs from that of the admitting nurse e.g. they ask the pt/family on admission if they have fallen within the past 6 months and are told no or the information is not available, and we see from looking through the chart that falls have been documented within this timeframe?
2. is the admission information the only source used or will the complications be taken into consideration e.g. if the pt develops a new cva as a complication do we redo the overstay predictor?

coding of extra diagnoses

Lacunar Strokes

Should lacunes or lacunar infarcts that are/have been asymptomatic but are reported on a CT be included as CVAs in the comorbids?

• No. If no physical/funtional impairment what so ever then no, don't code.--Trish Ostryzniuk 15:52, 2012 April 27 (CDT)
  • They should be reported like they always have been. We are basing the algorithm on previous data. This does not preclude us from discussing that question independently on the appropriate wiki page. Trish, I have no idea what a lacunar infarct is, could you provide the link? Ttenbergen 12:47, 2012 April 27 (CDT)
• If I read that question and the wikipedia article, then I wonder: are talking about Silent lacunar infarctions only here? Surely if there are symptom's it's coded, no? But as what code? Did we enter them into the comorbids before? Either way, this should probably be coded at the appropriate article, not here. Ttenbergen 17:54, 2012 April 27 (CDT)

Intracerebral hemorrhages in comorbids

We code Intracerebral hemorrhage (ICH) as 502** if it is a diagnosis, but we don't have a comorbid code for it.

1. Should ICHs be considered CVA in comorbids?
   • Yes if it caused a stroke then code 505 in comorbid.
   • They should be reported like they always have been. We are basing the algorithm on previous data. This does not preclude us from discussing that question independently on the appropriate wiki page. Trish, I have no idea what a ICH is, could you provide the link? Ttenbergen 12:47, 2012 April 27 (CDT)

Did we consider all alternative diagnosis for CVA

We code several diagnosis as alternatives to a CVA-Cerebral Vascular Accident:

• Intracerebral hemorrhage and subcodes
• Brain Stem Hemorrhage
• how about Cerebral Infarct Cause NYD
• are there more? Template:Discussion

Whether they should be included in our algorithm depends on how we code them. Neither article gives instructions to code in addition to or instead of CVA 505 (we have this instruction for some other dxs). What is the coding practice? Template:Discussion

current status

• as of 2012-04-27
  • only CVA 505 is included in the algorithm to generate the colour
  • only data pertaining to CVA 505 was given to Rodrigo (the programmer) for overstay analysis
  • This issue might be relevant for other topics like the MOST score and wherever else we report on CVA, such as MOST and APACHE

• I have sent an email to the overstay team for advice. Ttenbergen 18:28, 2012 April 27 (CDT)

• • Dr. Dan Roberts:

Strokes would include all intracranial hemmorhages 
as well as ischaemic thromboembolic events for this 
purpose. Other inclusions would be spinal cord events 
resulting in new paraplegia or quadreplegia.
These are neurologic insults that almost invariably 
lead to permanent severe physical plus or minus 
cognitive disability.

We will need to re-evaluate the algorithm with this in mind. Linda will discuss with Rodrigo and Dr Roberts at the next overstay meeting May 3. Ttenbergen 14:02, 2012 April 30 (CDT)

1. I intentionally left out one of the overstay questions in the temp file expecting to get a gray overstay predictor score indicating missing information but am getting yellow-is this correct?

Purpose

A small number of patients overstays for a significant amount of time after they are medically ready for discharge. Though the number of patients is small, a significant proportion of bed-days is wasted in the process. We are piloting a process at the Grace where an "overstay coordinator" will be assigned to patients at risk of overstaying. Whether a patient is at risk is determined by the ward nurse assessing risk factors on a form, and by an assessment algorithm that takes into account the values mentioned as mandatory above; the combination of these results in a chart being assigned a colour sticker, and the transition coordinators monitor these chart stickers.